WHY did The Pilots CONTINUE?! Asiana flight 214

foreign is on Final approaching to San Francisco Airport from the onset it looks like any other approach but then as the aircraft is getting closer to Runway it starts dropping down way below its normal descent pot the pilots tried to pull the nose up but it doesn't help what is happening stay tuned whenever an accident happens it's always the result of a long line of interconnected mistakes circumstances and Technical factors often stretching many months or even years back in time sometimes it goes as far back as to the construction of the aircraft but for this story we will start in a classroom belonging to a Korean Airline called aseana back in March 2013. in the classroom a group of command upgrade candidates are listening closely to a Technical Systems lesson about the aircraft they're about to become captains on the Boeing triple seven and one of these students in the class will become the pilot flying in the story that I'm about to tell you the reason we start this story here is because on this day the class is watching an instructional video created in one of Asiana Airlines simulators about the speed protection systems on the Boeing triple seven the triple seven is a fantastic aircraft with very Advanced autoflight system it includes flight directors who are giving the pilots visual instructions on their screens showing them how to fly it also has a set of autopilots who are capable of maneuvering the aircraft during All Phases of light and an outer throttle system that keeps the required speed of the aircraft and also provides critical low speed protection even if the system is Switched Off it was this autotropyl systems that the students were learning about on this particular day and the class watched a video on how the simulator Pilots turned off the autopilot and the outer throttle the trust levels to idle and then let the aircraft speed reduce until it became close to the indicated stall speed the speed where the aircraft would no longer be able to fly at that point the then Switched Off outer throttle suddenly woke up engaged itself in speed mode on the FMA in front of the pilot and increased the thrust to keep the aircraft from stalling this feature made a deep impression on the pilot of our story and he later explained how amazed he was about this fantastic safety feature he had recently gone from a command position where he had been flying the Airbus A320 and in the Airbus they had a similar system called Alpha floor protection the problem with the presentation that these students received was that the outer throttle did not always protect the aircraft from a low speed event when certain modes of the outer throttle was engaged it would not move even if the speed became very low and there was no wake up feature available then this would happen when the outer throttle engaged in hold mode as it did sometimes when a pitch Mode called level change was used and it could also happen when it engaged in toga mode and when the aircraft was below 400 feet of the takeoff and 100 feet during approach these exceptions were not highlighted during the presentation and they were generally quite poorly understood by most of the pilots flying the Boeing triple seven at the time Asiana Airlines had as an airline policy to maximize the use of automatic systems during All Phases of flight and although the use of automation has played a major role in improving overall safety in the industry the policy will come to play a negative role in this story our pilot completed the training for his type rating on the Boeing Triple 7 and started what's called operational experience training or line training in June 2013. during the Simulator part of his training he had received generally good or even very good Training remarks from his instructors and he was looking forward to the line training at the time this flight took place he was 45 years old and he had a total flying experience of around 9700 hours of which over 3700 was flown as a captain previous to the accident flight he had flown about 33 hours of his line training on the Boeing triple seven making him very inexperienced on the type but very experienced overall his line training had up until this point been going well with good remarks from the majority of his line training captains except from one who had made remarks about his organization and preparation before their flight on the accident day the captain on the training was joined in the cockpit by a 49 year old instructor captain the instructor was very experienced with just over 12 300 hours of Total time of much more than 3200 was flown on the Boeing triple seven he had recently gone through his instructor training on the type and the accident flight was actually his first ever flight with a real student after his training now before we continue I feel that here it's a little bit important to tell you a bit about some of the peculiarities with command instruction to the untrained eye command training might sound like a fairly easy day out for an instructor after all you're instructing an already experience and hopefully very well prepared student the reality is that good command training involves the instructor doing three different roles successfully which is both hard and quite tiring on the accident date the 6th of July 2013 the crew had prepared for a flight from their home base Incheon International in Seoul South Korea to San Francisco International in the United States this flight was scheduled to last close to 10 and a half hours and Asiana had assigned four Pilots to operate the flight the captain on the training would be the primary Pilot Flying for takeoff and Landing together with the instructor pilot who was going to be pilot monitoring and then on top of that a relief crew consisting of one captain and one first officer would take over for a few hours during cruise to let the primary flight crew go back to business class and have some rests since this was a training flight the relief first officer will also stay in the cockpit during takeoff and Landing to act as a third set of eyes for the operating crew but why was there a full relief crew needed on the flight if it was just over 10 and a half hours long well the landing time was scheduled to be around 11 30 pacific daylight time in San Francisco making it around 0-3 30 in the morning in Seoul that meant that they would land smack in the middle of the window of circadian low and that's the time of the night where we humans really just want to sleep and our decision-making skills and cognitive abilities can be impaired by acute fatigue even if you're allowed to have a nap flying during these times of night can still have an effect on us picture yourself driving a car at 3 30 in the morning and you know exactly what I mean and this is worth remembering for what's about to happen [Music] Queen triple seven 200 ER which the crew was operating was in full working order and the technical status of the aircraft did not have any impact on this accident on board the flights there were 291 passengers 12 cabin crew and four pilots in total the initial part of the flight was completely uneventful the pilots had their rest as planned and at time 0955 the primary flight crew took back controls from the relief Pilots to start preparing for their arrival into San Francisco about 50 minutes later the pilot flying the trainee Captain who was going to fly the approach handed over the controls to the instructor and started setting up and briefing for the approach they had already discussed the fact that the instrument Landing system Glide slope in San Francisco was turned off due to some construction work and that they would expect to get radar vectors towards a visual approach into Runway 2 8 left a visual approach is exactly what it sounds like it is an approach where the crew needs to visually see the runway and fly the approach based on visual cues instead of using their instruments it is a fairly standard maneuver that we often do when the weather is good because it can allow us to shorten down the track miles we need to fly and therefore save both Fuel and time but we can also do it like in this case if the ILS is not working it is however a type of approach that is prone to a lot of Errors if it's not planned and executed correctly and as I mentioned before the Asiana procedures stipulates that all approaches including visual approaches should be flown using the autopilot the captain went through the approach briefing but he didn't tell his instructor that he was a bit nervous for the approach he was not yet fully confident with the aircraft and had only flown ILS approaches so far this was going to be his first ever visual approach in the Boeing triple seven the fact that he didn't say anything to the instructor likely was because he didn't want to show this potential weakness to his instructor but it is a little bit strange since he had also indicated that he really liked this instructor and he thought that he was more open and friendly than other instructors that he'd flown with but sometimes Pride can be a powerful thing I guess in any case if he had voices concerned at this point it is likely that the instructor would have spent more time helping him build a mental model of what to expect what automation modes to use and highlighting cockpit instruments and AIDS that he could use to help him but now that did not happen during the briefing the captain said that he would use the localizer to establish himself on the sand line and he would use vertical speed to manage The Descent path He also mentioned that he would use the outer throttle to maintain the speed the pilot set their minimum descent altitude or their minimum up to 460 feet and the captain said that he would set the missed approach altitude to 3000 feet when they started their final descent during the approach the approach reference speed was decided to 132 knots with a wind additive of five knots making the Final Approach speed to fly 137 knots the weather was really nice with only some few clouds good visibility and light winds perfect for a visual approach at time 10 48 the crew completed their descent checklist and the relief first officer returned to the cockpit for his Observer duties the aircraft contacted air traffic control and received their first descent clearance down towards San Francisco but before we get into the accident sequence of this video I just want to share this short message from our sponsor who helps me create these videos are you looking for new and really interesting things to watch well in that case let me introduce you to today's sponsor curiositystream curiositystream or a subscription streaming service with thousands of documentaries and non-fictional titles from some of the best filmmakers in the world and you can get access to them for a very reasonable price of less than 20 dollars a year if you like me love space and astronomy I 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aircraft up with the final for Runway 2-8 left at time 11 22 the NorCal approach controller asked the crew if they had the runway inside and the pilot monitoring the instructor pilot responded that they did indeed see the runway the control it and continued and clear them for the visual approach for Runway 2 8 left at this point the aircraft was at 6 300 feet descending using The Descent mode level change and with the speed of 211 knots the pile of flying told the pilot monitoring that he would arm the localizer in order to capture the Final Approach track and the pilot monitoring responded check so far so good the crew then discussed the next altitude to set in the mode control panel and after having consulted the approach plate they decided that this would be 3100 feet which corresponded to the lowest altitude over the r nav Point here man located on the extended Center Line when the aircraft passed 15.4 nautical miles from the runway the localizer was captured and the aircraft descended through 5 300 feet a Rough Guide to how many track miles we Pilots need in order to descend in a controlled way is to take your altitude times three providing of course that you have your speed under control so if we do this in this case it looks like they are doing quite okay they might be a little bit high but not much this will soon change now in order to understand what happens next I'm going to need to explain how two of the autopilot pitch modes that the Boeing Triple 7 has works so let's start with level change which is the mode that the aircraft was using at this point in level change if the mode control panel altitude selector is set to a lower altitude the aircraft is currently at the outer throttle will drive the thrust to idle and then switch over to the hold mode when the idle is reached the aircraft nose will pitch down enough to give a decent rate that keeps the selected mCP speed constant this means that if you select for example a lower speed the aircraft will reduce the decent rate by pitching those up to maintain this lower speed but the trust will stay in idle and in the hold mode as long as the autotrottle stays in hold the pilot can manually change the truss levers but the outer throttle in itself will not move it not even if the speed is getting too low that's a detail that's worth remembering if the altitude on the mCP altitude selector is set to a higher altitude than the aircraft is at well then the aircraft will assume that the pilots wanted to climb so the outer throttle will drive the trust up to maximum N1 value and the autopilot will pitch up once again to maintain the selected speed and get the aircraft climbing so in level change the aircraft speed is governed by the aircraft's pitch with the trust either in idle or full climb the other modes we need to discuss is vertical speed which is what the pilot flying had briefed that he was going to use during the approach in this mode the autopilot will try to achieve whatever vertical speed value that the pilot selects on the mCP selector and the outer throttle will adjust to try to maintain the selected speed so this means that in vertical speed mode the trust controls the speed and not the pitch understanding the differences between these modes is very important for any pilot operating the aircraft but also for you in order to understand why this accident happened at time 1123 the pilot monitoring suggested to change the mCP altitude to 1800 feet and descend slowly to that altitude visually this was the minimum altitude over a point called duyet which was also the Final Approach point the pilot flying agreed to this he set 1800 feet on the mCP and then asked for flaps one which the palette monitoring selected now when we select flaps we generally do this in order to enable the aircraft to decelerate to a lower speed in order to prepare for landing the problem is though that depending on which pitch mode we use the aircraft might try to achieve the speed reduction in ways which are not suitable for the situation and what happens next is a great example of that because the norcold controller now called the aircraft up and asked them to reduce the speed to 180 knots and maintain that speed to 5 nautical miles final this is a pretty standard instruction that we very often get and it's done because it helps the controllers to separate aircraft on approach Asiana 214 was at this point maintaining a speed of 250 knots with a descent rate of around 900 feet per minute and the pallet flying responded to this instruction by selecting 180 knots and asking for flaps 5. still in level change do you remember how the level change mode acted in order to reduce the speed yes it does so by raising the nose and that's exactly what now happened the vertical speed reduced from 900 feet per minute to around 300 feet per minute so why is this a problem well remember how I said that the aircraft was previously on the correct descent profile maybe just a tiny little bit High well by doing this now the pilots are now putting the aircraft in a position where it's becoming higher and higher above the correct descent profile the correct thing to have done here would have been to keep the soundtrack going with use of for example vertical speed and increase the drag by using speed brake or selecting more flaps that way the aircraft would have both descended and slowed down at the same time but unfortunately that's not what happened the pilot monitoring the instructor now made a comment that couldn't be properly heard on the cockpit voice recorder and a few seconds later the selected speed was reduced even further to 172 knots the pilot flying said yeah I'm descending now and change the pitch mode from Level change to vertical speed and selected 900 feet per minute the pilot monitoring responded 1000 and the power flying increased the vertical speed to 1000 feet per minute it is likely that the pilot monitoring was spotting the issue here and wanted to start getting the aircraft to descend a bit quicker now in the cockpit on the navigation display there is a small instrument known as the vertical path indicator this instrument shows exactly how high or low the aircraft is in reference to the calculated Optimum profile and it is available even when there is no Glide slope available now it doesn't seem like the pilot flying was aware of or used this instrument because it would have shown the aircraft around 900 feet above profile at this point which is quite High especially this close to the airport the aircraft was now getting closer to landing and at time 11 24 and 32 seconds the aircraft was nine and a half miles away from the runway at 3 900 feet with an indicated airspeed of 185 knots Now The Observer pilot speaks up for the first time and reminds the crew that they have to maintain 180 knots to 5 miles he repeated this again a few seconds later and here we can see the first indication of a higher than normal workload affecting the pilot flying remember he is flying a visual approach and it would be quite obvious at this point that he was becoming high on Profile 30 seconds later the pilot flying asked for the landing gear to be extended and this is a good thing to do if you're high as it adds a significant amount of drag which can help the aircraft to descend he could have also asked for more flaps to be selected but he didn't do that instead the pilot monitoring said um it seems a little high which the pilot flying acknowledged and That Was Then followed by a repeated yeah this should be a bit high from the pilot monitoring clearly showing some unease with the situation that they were now finding themselves in the pile of flying probably sensed this unease from his collar gear because he said uh you mean it's too high and I will descend a bit more after which he increased the vertical speed to 1500 feet per minute 23 seconds later the pilot monitoring motor is something followed by okay and 1000 and the pile of flying now change the vertical speed back to 1000 feet per minute even though the aircraft was still high at this point and it is unclear why that happened now the NorCal air traffic controller calls the aircraft up and asked them to change over to the San Francisco Tower controller this instruction was read back by the pilot monitoring and at the same time as that was happening the pilot flying changed the mCP altitude selected to 3000 feet in preparation for a possible missed approach like he had briefed earlier now this action is going to become really important very soon when the aircraft passed the Final Approach point due yet they were at an altitude of 2250 feet that's 450 feet higher than the published correct altitude now that might not sound like a lot but this late in the approach it's a real problem the pilot monitoring called up the tower controller and as he was doing that the polar flying asked for flaps 20 to be selected the pilot monitoring responded flops 5 uh flop 20. from The Voice transcripts you can tell that there is some real workload increase starting to hit both Pilots at this point the aircraft is now descending with 1000 feet per minute which is more than a normal 750 feet per minute that a normal Glide slope requires but it's far less than what's needed to get this aircraft back on the correct descent profile before the landing gate at 500 feet the pile of flying Now set the mCP speed to 152 knots and ask for flap 30 but the speed was still at 175 knots which was higher than the maximum speed for flaps 30. this meant that the pilot monitoring couldn't extend it the pilot monitoring did respond speed checks flaps 30 but it didn't actually select it it's very likely that the pilot monitoring was now focusing almost all of his attention on the speed tape at this point waiting for the speed to drop the next thing that happened was that the pilot flying suddenly selected level change mode on the mCP but he didn't call this out to his colleague this meant that the pilot monitoring didn't notice this change in Pitch mode likely also because it was fixated on waiting for the speed to drop low enough so that he could select the flaps 30 that pile of flying had asked for this had some immediate consequences first the mCP selected altitude was now above the aircraft remember it was set to 3 000 feet for the missed approach so the autopilot started pitching up to reach the target airspeed of 152 knots and climbed up to the selected altitude secondly the outer throttle started advancing the trust to facilitate this climb just as the other throttle should do this was obviously not what the pilot flying wanted so why did he do this well it is likely that he pressed level change because that mode tends to generate higher decent rate during normal circumstances earlier on in The Descent when a higher speed is used but during the approach and especially with a high energy situation that this aircraft was in this was a completely inappropriate mode to use it seemed like the pile of flying immediately realized this mistake because the next thing that happened was a modded word from him including the word sir and then the autopilot was disengaged the trust levers were still engaged as per procedure but they were now manually forced back into idle and that caused the outer throttle to switch into the hold mode and do you remember what type of protection was not available in the hold mode correct the speed anyway none of the pilots noticed this change of outer throttle mode in the FMA the pile of flying was likely busy looking outside where he would now clearly see four white populates telling him that he was way too high and the pilot monitoring finally managed to select flaps 30 as the speed had now finally gotten low enough for him to do that pilot monitoring also called out flight director as the autopilot had been disconnected and the pile of flying responded check the palaflying now asks for the Final Approach speed of 137 knots to be set as he now manually also started pitching down the nose to regain the correct path he also asked the pilot monitoring to turn off the flight directors this was an unofficial procedure in asean at the time where during the manual segment of a visual approach the flight directors should be switched off and then switched back on again on the pilot monitoring side this way there wouldn't be any unnecessary information on the pile of flying's primary flight display but the pilot monitoring would still have it if needed unfortunately in this case the pilot monitoring only turned off the flight directors on the pilot flying side but he didn't recycle his own if he would have done that the outer throttle would have gone out of the hold mode and the speed protection would have been available again the aircraft now descended through 1000 feet still around 250 feet too high and with a speed of 151 knots the vertical speed had now increased to 1 500 feet per minute again well above the company limit of 1000 feet per minute below a thousand feet The Observer pilot call out sync rate sir and repeated that again as the decent rate continued to increase to close to 1 800 feet per minute this happened at the same time as the pilot monitoring was calling the tower informing them that they were on short Final in order to prompt the tower to issue their Landing clearance the pilot flying responded Yes sir to the sync rate prompt and started pitching back up to reduce the decent rate but the trust remained in idle the tower controller now clear the aircraft's land and as that coal was coming in a third sink rate call was made by one of the pilots it's unclear who would call it at time 11 27 and 17 seconds the aircraft descended through the landing gate of 500 feet at this point the aircraft had to be stabilized with all checklist complete on path on speed and with correct decent rate and thrust set they were almost back on profile but the decent rate was still 1200 feet per minute and the trust was at idle therefore the aircraft was not to be considered stabilized and that should have prompted the pilots to go around at this point unfortunately this did not happen either because the crew members thought that they were just about to stabilize their approach or because these unstabilized parameters weren't really fully recognized by the crew as the aircraft continued to descend through 460 feet deep minimums coal was heard in the cockpit and the pilot flying asked if the landing checklist was complete the pilot monitoring responded that yes it was the speed was now 134 knots decelerating and still with a decent rate of 1 100 feet per minute causing the aircraft to get lower and catching up with The Descent profile in fact they now actually started dipping below the correct descent path for the first time and that was shown by the purpose going from two red lights to three Reds when the pilot flying saw this he started pitching up to remain on the path because he knew that if those poppies went to four Reds he would fail this line training sector and that likely affected the workload that he was feeling at this point since the aircraft was now pitching up with the trust still at idle the speed started dropping quickly now this is precisely the problem with continuing on stabilized approaches since there's so many moving parameters to monitor it's easy to miss just some of them leading up to an unsafe aircraft State when the aircraft passed one nautical mile away from the runway its altitude was 331 feet with a speed of 130 knots they continue to descend with 900 feet per minute and the pitch of the aircraft increased from 2 degrees to 7 degrees as the speed continued to degrees now this change in Pitch must have been quite heavy work for the pilot flying because during this whole manual segment of the flight he didn't trim the aircraft even once to reduce the Yoke forces this could be a sign of a lack of manual flying practice but it could also possibly be a reversal to its previous flying experience on the Airbus A320 where he wouldn't have needed to trim when he was flying manually anyway at 0.7 nautical miles the speed had reduced to 122 knots and it just kept decreasing around this time the poppies went to four Reds indicating that the aircraft was now well below the Glide port and no longer in a safe approach condition but the approach still continued 200. call out now sounded from the gpws and the pilot monitoring said it's low but he didn't clarify if he was referring to the altitude or speed which were both dangerously low at this point the pile of flying responded yeah now a bright Reflection from something outside momentarily blinded the pilot flying and that made him look down onto his instruments finally recognizing the low speed at almost exactly the same point the low speed quadruple chime sounded in the cockpit warning the pilots that the aircraft is now close to stalling the pilot monitoring Now call out speed and pushed the trust levers forward in the background they call 100 was heard at the lowest speed of this flight was recorded 103 knots 29 knots below the calculator touchdown speed the pilot flying now started pitching up but as he did so this stick shakers immediately activated due to the low speed the giant engine started to accelerate up toward full thrust and the aircraft started accelerating but it was too late the last call out recorded from the crew was the pilot monitoring calling go around about one second before the aircraft impacted the sea wall just short of the threshold to Runway 28 left the first thing to hit was the main landing gear which was then immediately sheared off as it was designed to do after that the tail of the aircraft impacted and was torn off in the area around the after pressure bulkhead when the tail Departed the aircraft two passengers and four flight attendants were ejected from the hole that opened up in the cabin the aircraft now slid along the runway and both engines sheared off the back of the aircraft then started rising up in the air and the whole aircraft cart wheeled over turning almost 330 degrees before it again impacted the ground and came to a final stop the dust soon settled over the wreckage of the Boeing triple seven as it lie left of the runway but inside of the aircraft in a testament to the incredible durability of this design most of the passengers and crew were still alive the impact that caused two slides to activate inside of the cabin pinning two flight attendants to their seats and making those emergency exits impossible to use the Purser quickly entered the cockpit and asked the pilots if they should evacuate but he was told to initially wait by the pilots who were still getting their Barons back the pilots now called up the tower and were advised that the emergency response Vehicles were on their way they made several calls but eventually as the severity of the situation dawned on them they managed to locate the qra checklist execute the required items and then initiate the evacuation about one and a half minutes after the aircraft had come to a complete stop the evacuation was well handled by the cabin crew using the few emergency exits which were still usable and they also soon received help from the fire firefighters who had arrived at the scene one of the firefighting Vehicles later unfortunately ran over one of the ejected passengers were lying on the ground covered in firefighting foam but the investigation showed that the passenger was already deceased at that point in total three people died in this accident and 40 passengers and crew received serious injuries the three fatalities included the two passengers who were ejected from the aircraft when the tail was torn off but the four cabin crew who were also ejected survived with the severe injuries the accident investigation started immediately after the rescue workers had finished their job and bought the cockpit voice recorder and the flight data recorder were in good condition this together with the fact that there were plenty of eyewitnesses and surviving crew and passengers helped investigation team immensely and the picture of what had actually happened quickly emerged the final report found that the accident was caused by several factors including that the pilots were likely suffering from some form of fatigue because of operation during the window of circadian low the pilots had mismanaged the aircraft vertical profile during the early part of the approach which then made it very hard for them to complete a stabilized approach as they were getting closer to the runway the issues they then had were trying to stabilize the approach increase the workload for the pilot monitoring which made him miss that the outer throttle did not guard the speed as anticipated the crew then failed to execute a missed approach when the aircraft was not stabilized below their 500 feet Landing gate and there was also non-standard communication and coordination between the pilots in terms of changes between different automation modes this caused the pilots to miss crucial changes in automation modes and also to not sufficiently monitor their flight parameters during the last stages of the approach the Asiana company policy of maximizing use of automatics in all different flight phases also likely caused an over-reliance on the automatic systems and low manual handling proficiency on behalf of their pilots the final report also noted the complexity of the Boeing triple Seven's Auto throttle mode design and the training that the palace had received which caused them to have a faulty understanding of the protections the outer throttle would give them all of this led to several recommendations to both Asiana Boeing and the fva and that has in turn led to increased manual Flight Training for Pilots worldwide including myself it has also led to better wording in the Boeing system manuals as well as a re-emphasis on the importance of doing Gore routes and if any approach is not stabilized if in doubt go around now check out this video next which is one of my absolute favorites or watch this playlist if you want to binge on more accident investigations if you want to join my patreon crew you will be invited to weekly Hangouts and you'll help me produce and improve these episodes have an absolutely fantastic day and I'll see you next time bye

Channel: Mentour Pilot

Views: 1,072,239

Keywords: storytelling, true crime, full episodes, investigation, documentary, entertainment, mentour pilot, mentour now, autothrottle, san francisco, SFO, idle, air crashes, investigations, documentary 2022, Mentour pilot crash, Air crash investigation, Seconds from disaster, Asiana flight 214, San Francisco crash, Mentour, Mentour pilot, How to become a pilot, Pilot life, Boeing 777, Boeing 777X, Boeing 747, Airbus A320, Autopilot, Fear of flying, Nervous flier, Fear of flying help

Id: 0pLRMJyD9TY

Length: 34min 54sec (2094 seconds)

Published: Sat Oct 29 2022